Foreword

From Cancer Guidelines Wiki


Foreword

Australia and New Zealand have the highest incidence of melanoma in the world, and comprehensive, up-to-date, evidence-based national guidelines for its management are therefore of great importance. Both countries have populations of predominantly Celtic origin, and in the course of day-to-day and recreational activities their citizens are inevitably subjected to high levels of solar UV exposure. These two factors are considered to be predominantly responsible for the very high incidence of melanoma (and other forms of skin cancer) in the two nations. In Australia melanoma is the third most common cancer in men and the fourth most common in women, with over 13,000 new cases and over 1,750 deaths each year. [1]

The purpose of evidence-based clinical guidelines for the management of any medical condition is to achieve early diagnosis whenever possible, make doctors and patients aware of the most effective treatment options, and minimise the financial burden on the health system by documenting investigations and therapies that are inappropriate. The first Australian guidelines for the management of melanoma were published in 1999 under the auspices of the Australian Cancer Network, whose CEO Professor Tom Reeve AC CBE encouraged and supported their development and promulgation. A multidisciplinary working party convened by Professor William McCarthy AM rigorously assessed all available evidence, and on this basis the guidelines received endorsement from the Australian National Health and Medical Research Council (NHMRC).[2] Within a few years it was clear that updating of the guidelines was required, and another working party was assembled, with myself as chairman, to produce new evidence-based guidelines. On this occasion, New Zealand representatives were included in the working party, and the resulting guidelines published in 2008 were endorsed not only by the NHMRC in Australia but also by the New Zealand Melanoma Guidelines Group [3]. NHMRC endorsement was achieved once again because that body was satisfied that its required process for the development of evidence-based guidelines had been followed.

In 2014, with many further advances in melanoma diagnosis and management having been made, it was apparent that yet another revision of the Australian melanoma management guidelines was necessary. However, there was concern that the process used to develop the two previous sets of national guidelines would be too protracted and cumbersome in an era when rapid advances in management are occurring. Nor was any funding readily available to proceed along the same lines as previously, i.e. following the strict NHMRC requirements for the production of guidelines. A possible solution to the problem was proposed by Professor Ian Olver AM, then CEO of Cancer Council Australia. He suggested that using an electronic “wiki” platform, guidelines could be produced in a way that allowed individual sections to be updated as new evidence became available. This method had already been used successfully by Cancer Council Australia to produce national clinical practice guidelines for the management of lung cancer, sarcoma,and Barrett’s oesophagus.

The web-based wiki platform supports all processes of guidelines development, such as the literature search, critical appraisal, data extraction, evidence assessment and summary processes, as well as content and recommendation development, online consultation, review and web publication. It is in line with the NHMRC guidelines requirements, designated standards of quality, process and grading system for recommendations.[4][5] An infrastructure is set in place to process literature updates and continuously update content as new evidence emerges and is reviewed. The Development of Clinical Practice Guidelines using Cancer Council Australia’s Cancer Guidelines Wiki Handbook illustrates the steps in the development of Cancer Council Australia’s web-based clinical practice guidelines. It provides information to assist working party members and staff members to develop concise clinical questions in “PICO” format (P=Population, I=Intervention, C=Comparison, O=Outcomes), construct sound search strategies, systematically search the literature, critically appraise, summarise the evidence and formulate guidelines recommendations.

To develop the new management guidelines, Melanoma Institute Australia agreed to work in partnership with CCA using its wiki platform, with both organisations contributing to funding and providing in-kind resources. I took on the role of chairman, and a small management committee was appointed to oversee the guidelines revision process. Subsequently, a full multidisciplinary working party of individuals from all relevant disciplines was recruited, together with consumer representatives and members of the Cancer Council Australia Clinical Guidelines Network, headed by Ms Jutta von Dincklage (see full membership). The Skin Cancer College Australasia later joined the project and provided additional funding to enable employment of an additional full-time project officer in the systematic review team.

In November 2014, at an initial meeting of the guidelines working party, 23 questions were identified as being of greatest importance, covering issues relating to diagnosis, staging and management of cutaneous melanoma. These questions were then prioritised and work commenced immediately, with relevant evidence collected for each question then critically appraised by the systematic review team. Each publication bearing on the question was structured according to the “PICO” format for the systematic review.[6] Small expert sub-committees, each headed by a lead author, were then given the task of formulating guidelines for the each clinical question and documenting the level of evidence supporting each recommendation. For matters outside the scope of the systematic review and when there was no good evidence available “practice points” were developed for inclusion in the guidelines (as in the two previously published Australian guidelines). Full details of the guidelines development process are given elsewhere.

An important contribution to the process of formal critical evaluation of available evidence, for which we are most grateful, was made by Professor Claus Garbe, Chairman of the German Dermatologic Cooperative Oncology Group (DeCOG) Committee on Guideline Development, who offered to let us use the systematic reviews that had recently been undertaken to produce updated German guidelines for melanoma management. These German guidelines had been published in 2013, so where the same questions were being considered, this greatly reduced the workload for the Australian systematic review team because they were able to limit update the systematic reviews with the publications that had appeared since 2012. In return, it was agreed that new data extractions and critical appraisals would be shared with the German group.

Made possible by use of the wiki platform, each chapter of the new Australian melanoma management guidelines will be published online when it is completed. After a draft has been prepared by each chapter group, it is released for public consultation, then finalised and approved for publication by the entire working group. At the time of preparing this Foreword the first four chapters have completed this process and are being published. They are:

  • Type of biopsy
  • Clinical features and atypical melanoma
  • When is a sentinel node biopsy indicated?
  • Recommended definitive margins for excision of primary melanoma

Subsequent chapters dealing with other important clinical questions will be published later, as they are completed and ratified by the working party, and chapters already published will be revised as relevant new evidence to guide management becomes available. These guidelines will thus be a living document, rather than a static printed publication that would inevitably be out of date within a very short time. It is hoped that wide dissemination of these guidelines and adherence to their recommendations will benefit melanoma patients in Australia by ensuring that they receive the most appropriate care.

Professor John Thompson AO

Chair, Melanoma Guidelines Working Party


Acknowledgments

The preparation of clinical guidelines of this nature involves a great deal of hard work by many people, and as chairman of the working party I acknowledge the contributions of all members of the group, particularly the chapter leaders. I also acknowledge those who undertook the arduous task of critical literature selection and appraisal, and the staff of the Clinical Guidelines Network of Cancer Council Australia, particularly its head Ms Jutta von Dincklage, who drove the project forward with great zeal and efficiency.

References

  1. Australian Institute of Health and Welfare. Melanoma of the skin. Vol. 2016. AIHW; 2016.
  2. Australian Cancer Network Melanoma Guidelines Revision Working Party. Clinical Practice Guidelines for the Management of Melanoma in Australia and New Zealand. Sydney: Cancer Council Australia and Australian Cancer Network and Wellington: New Zealand Guidelines Group; 2008.
  3. Australian Cancer Network Melanoma Guidelines Revision Working Party. Clinical Practice Guidelines for the Management of Melanoma in Australia and New Zealand. Wellington: The Cancer Council Australia and Australian Cancer Network, Sydney and New Zealand Guidelines Group 2008 Abstract available at http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp111.pdf.
  4. National Health and Medical Research Council. A guide to the development, evaluation and implementation of clinical practice guidelines. Commonwealth of Australia: National Health and Medical Research Council; 1999 Jan 1 Abstract available at http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp30.pdf.
  5. National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for guideline developers. Canberra: National Health and Medical Research Council; 2009 Available from: https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf.
  6. Clinical Guidelines Network Cancer Council Australia. Development of Clinical Practice Guidelines using Cancer Council Australia’s Cancer Guidelines Wiki. Handbook for section authors and the guideline working party. CCA Sydney; 2014 Available from: http://wiki.cancer.org.au/australiawiki/images/9/9b/CCA_Clinical_Practice_Guideline_Development_Handbook.pdf.